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Foot & Ankle Pain

Written 21st February 2020 - Last Update 25th August 2026

Foot & ankle pain (approach)

The regional hub for foot and ankle pain.

Key facts

  • Foot strain is probably the commonest cause of podalgia; foot deformities such as pes planus are often painless. Foot pain is present in up to 36% of adults and is more common in women, patients aged >55 years and patients who are obese.
  • Hallux valgus (± bunion) is the commonest toe deformity; OA is a common sequel. Ankle OA itself is relatively uncommon — but foot/ankle arthritis collectively still accounts for an estimated 152,000 GP encounters nationally each year, mostly in patients aged 65–74; a weight-bearing X-ray is the mainstay of diagnosis, and ultrasound-guided steroid injection (given the small joint spaces) can reduce pain and delay surgery once non-operative measures have failed.
  • Many problems come down to unsuitable footwear and poor foot care.
  • Ankle sprains are the most common sporting injury (~25%) — and not innocuous: associated chondral/talar-dome fractures, medial-recess impaction fractures, and avulsions of the lateral malleolus or 5th metatarsal base. Approximately 70% of lateral ankle sprains involve injury to the ATFL, often in isolation. Early functional rehabilitation (protection, optimal loading, ice, compression, elevation) is preferred over prolonged immobilisation. A Cochrane review found therapeutic ultrasound does not enhance recovery or reduce pain and swelling after an acute sprain, so don’t rely on it. Chronic lateral instability follows 10–20% of ankle sprains; a short course of supervised neuromuscular/balance training gives short-term functional improvement, and surgery is reserved for instability that persists despite conservative treatment.
  • Navicular stress fracture behaves like the scaphoid — delayed union/non-union; 8 weeks of cast immobilisation early may avoid surgery. It’s one of several high-risk stress fractures needing urgent referral and non-weight-bearing immobilisation (with the others below, under Red flags) because of their propensity for non-union.
  • Plantar fasciitis affects up to 10% of people over a lifetime, peaks age 40–60, and is provoked by running, a tight gastrocnemius/Achilles contracture, and obesity. Patients commonly describe pain first thing in the morning or when arising from a seated position that improves over the course of the day. A calcaneal (“heel”) spur on X-ray is present in only about half of patients with plantar fasciitis, so its absence doesn’t exclude the diagnosis and its presence doesn’t confirm it. Most patients (~90%) improve, though recovery can take up to 12 months; a Cochrane review found local steroid injection may slightly reduce heel pain for up to a month but not beyond, is only low-quality evidence, and carries a small risk of plantar fascia rupture or injection-site infection.
  • Complete Achilles rupture is missed because the patient can still plantar flex (long flexors intact) — use the Simmonds/Thompson squeeze test.
  • Don’t overlook tibialis posterior tendinopathy as a cause of medial ankle pain, and diabetes (neuropathy + small-vessel disease) as a cause of foot pain.

Red flags

  • Pain in the forefoot disturbing sleep
  • Fever and systemic illness with bone pain
  • Localised tenderness away from the heel in a child
  • “Burning” feet
  • High-risk stress fracture sites — urgent referral, not just a CAM boot: navicular, anterior tibial cortex, fifth metatarsal shaft, sesamoid bones, medial malleolus. For fractures at these sites, immediate immobilisation in a controlled ankle motion (CAM) boot or below-knee cast and advice to be non-weight bearing, followed by referral to an orthopaedic surgeon with subspeciality training in the foot and ankle or a sport and exercise physician, is appropriate due to the propensity for these injuries to progress to non-union. Most other foot/ankle stress fractures (commonly a metatarsal shaft) can weight-bear in a CAM boot from diagnosis.
  • Stress-fracture pain that is worse at night, or described as “a toothache in the foot” — think stress fracture even without a clear history of trauma, especially with a recent change in exercise volume, dietary restriction, or (in women) menstrual irregularity.

Heel pain by site

SiteCommon sources
PosteriorAchilles tendon insertion; superficial calcaneal bursa; posterior soft-tissue/os trigonum impingement (active people); calcaneal apophysitis (Sever) in adolescents
InferiorPlantar fascia; calcaneal fat pad
MedialTibialis posterior tendon/sheath (and insertion/apophysis in adolescents); posterior tibial nerve in the tarsal tunnel (tingling)
LateralLateral ankle ligaments; sinus tarsi; peroneal tendinopathy/tenosynovitis ± subluxation; peroneus brevis insertion / base of 5th MT (adolescents, post-sprain)
Deep/vagueSubtalar joint; bone pain — calcaneus, talus, navicular

Less common: sural or medial/lateral calcaneal nerves, FHL and sheath, abductor hallucis, deltoid/spring ligaments, cubometatarsal joint, medial malleolus.